Wiki Covid documentation in the ER - PROFEE SIDE

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rmitchell

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A patient comes into the ER for SOB, fever and cough and a COVID test is ordered. The provider does not state a definitive diagnosis in the note, however, when verifying the ER orders and viewing the ER care timeline in EPIC we can see the test is COVID positive. From a compliance standpoint, is it correct to code from the test results since they show up in the ER orders and on the ER care timeline OR does the provider have to state it in the actual documented note.

Thank you!
 
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Hi
You have the lab proof and have seen it in which it is a valid bacteria and the patient and document is done...yes add the proof to supplement the ds. Also you can use dx. B97.89 or B96.89 as appropriate per documentation if not have exact name of bacteria causing illness. But if it is COVID infection Dx. B34.2 or B97.29 would be a great add on dx code. Also check with your coding protocal in your medical office.

Oh yes, please eyeball page 5 of the ICD10 CM year 2020 manual too it states some diagnostic disease tell you to add supplement infectious code if you have proof.
I hope I helped you a bit.
Lady T :cool:
 
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The AHA and CDC guidance for COVID-19 coding is that U07.1 may be assigned based on a positive test result, as an exception to the usual rule that requires the provider document the diagnosis.

See the Frequently Asked Questions Regarding ICD-10-CM Coding for COVID-19 | AHA:

"...the positive test results can be coded as confirmed COVID-19 cases as long as the test result itself is part of the medical record. As stated in the coding guidelines for COVID-19 infections that went into effect on April 1, code U07.1 may be assigned based on results of a positive test as well as when COVID-19 is documented by the provider. Please note that this advice is limited to cases related to COVID-19 and not the coding of other laboratory tests."
 
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